Method and system for acquiring claims in a health services environment

ABSTRACT

Methods and systems for acquiring claims in health services environments are presented. An exemplary method for processing service provider claims for payment includes: scheduling appointments with the service providers, receiving claims from the service providers, analyzing the scheduled appointments to identify at least one scheduled appointment corresponding to each of the received claims, automatically detecting scheduled appointments not identified as corresponding to any of the received claims within a predetermined period of time, and notifying respective service providers that no claims have been received for the detected scheduled appointments. Optionally, the method includes analyzing appointment information associated with a scheduled appointment to determine an anticipated number of received claims corresponding to the scheduled appointment, and automatically flagging the scheduled appointment for resolution when the scheduled appointment is identified as corresponding to fewer than the anticipated number of received claims within a predetermined period of time.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional application of U.S. patent applicationSer. No. 11/412,836, filed Apr. 28, 2006, which is herein incorporatedby reference in its entirety.

BACKGROUND

Conventional systems and methods for processing claims in a healthservices environment do not readily detect errors and acts of fraud,particularly with respect to medical services that were not performed,incorrectly coded, coded against the wrong patient, etc. Typically, thescheduling of appointments, receiving of claims, and validating andpayment of claims are performed by different specialized entities asdisparate processes in a serial workflow, in which data is passed fromone entity to another, often resulting in claims and payments beingdelayed or even lost. Furthermore, conventional claims processingsystems and methods rely on validating received claims by manuallychecking for inconsistencies or other indicators that the claim isinvalid, duplicative, in error, or fraudulent. This prior process istime consuming and prone to errors, resulting in received claims beingsubstantially delayed in payment, not being paid correctly, or beingpaid without assurance as to whether the received claim is a validclaim.

SUMMARY

Methods and systems for acquiring claims in a health servicesenvironment are presented.

An exemplary method for processing service provider claims for paymentincludes: scheduling appointments with the service providers; receivingclaims from the service providers; analyzing the scheduled appointmentsto identify at least one scheduled appointment corresponding to each ofthe received claims; automatically detecting scheduled appointments notidentified as corresponding to any of the received claims within apredetermined period of time; and notifying respective service providersthat no claims have been received for the detected scheduledappointments.

An exemplary system for processing service provider claims for paymentincludes: a scheduling module configured to schedule appointments withthe service providers; a claim intake module configured to receiveclaims from the service providers; an adjudication module configured toidentify at least one scheduled appointment corresponding to each of thereceived claims; and a claims acquisition module configured toautomatically detect scheduled appointments not identified by theadjudication module as corresponding to any of the received claimswithin a predetermined period of time and notify respective serviceproviders that no claims have been received for the detected scheduledappointments.

Another exemplary system for processing service provider claims forpayment includes: means for scheduling appointments with the serviceproviders;

means for receiving claims from the service providers; means foranalyzing the scheduled appointments to identify at least one scheduledappointment corresponding to each of the received claims; and means forautomatically detecting scheduled appointments not identified by theanalyzing means as corresponding to any of the received claims within apredetermined period of time and notifying respective service providersthat no claims have been received for the detected scheduledappointments.

BRIEF DESCRIPTION OF THE DRAWINGS

Other objects and advantages of the invention will become apparent tothose skilled in the relevant art(s) upon reading the following detaileddescription of preferred embodiments, in conjunction with theaccompanying drawings, in which like reference numerals have been usedto designate like elements, and in which:

FIGS. 1-8 illustrate process flowcharts providing exemplary steps fordetermining the appropriateness of service provider claims for payment;

FIG. 9 illustrates a exemplary high-level network for implementing asystem for determining the appropriateness of service provider claimsfor payment; and

FIGS. 10A-10X illustrate screen captures of an exemplary implementationof the systems and methods described herein for determining theappropriateness of service provider claims for payment, in the contextof providing health care services to inmate patients in a correctionalinstitution.

DETAILED DESCRIPTION

A detailed description of systems and methods for determining theappropriateness of service provider claims for payment is presentedbelow. The explanation will be by way of exemplary embodiments to whichthe present invention is not limited.

By integrating the scheduling of appointments with service providerswith the processing of claims from the service providers for servicesrendered, the systems and methods described herein may yield manyadvantages over systems and methods specializing in any one theseaspects alone. By gathering information from inception to completion forany particular appointment, the systems and methods described herein arecapable of rendering payment to the service providers in a more timelyand accurate fashion. In particular, by generating information abouteach scheduled appointment, an approximate type and number of claimsthat should be received from service providers for each scheduledappointment can be estimated. In this way, a particular claim can bereviewed with greater accuracy when an appointment that corresponds tothe claim is identified. The systems and methods described hereinautomatically match scheduled appointments to received claims with highspeed and accuracy thereby reducing the risk of payment of erroneous,duplicate, or fraudulent claims. Furthermore, proper payment of allanticipated claims for a particular appointment can be better ensuredusing certain aspects of exemplary embodiments. For example, because thesystems and methods described herein can automatically identifyappointments for which no claims have been received, the serviceproviders can be contacted and prompted to submit the outstandingclaims. Thus, institutions are less likely to pay for the claims thatthey should not pay, and the service providers rendering the servicesare more likely to be paid for all of the claims for which they shouldbe paid.

Process Overview

FIGS. 1-8 illustrate exemplary steps for a process 100 for determiningthe appropriateness of service provider claims for payment. Not all ofthe steps of FIG. 1 have to occur in the order shown, as will beapparent to persons skilled in the relevant art(s) based on theteachings herein. Other operational and structural embodiments will beapparent to persons skilled in the relevant art(s) based on thefollowing discussion. These steps are described in detail below.

First, in step 105, appointments for patients are scheduled with serviceproviders based on requests for services. For example, when a clientinstitution has a patient in need of health care services, the clientinstitution securely forwards information about the patient and thedesired appointment to a scheduler in the form of an electronic request.

FIG. 2 illustrates detailed steps for executing step 105. In step 205,an electronic referral is created for each of the requests. Whileelectronic referrals are preferred, they can be created innon-electronic format. Although, eventually the information from anon-electronic referral would likely be captured electronically, eitherin the form of an image of the non-electronic referral or, in othercircumstances, the information would be keyed in from the non-electronicreferral. As will be described in more detail below with respect to thedetailed description of the exemplary implementation, each electronicreferral includes the patient and desired appointment informationsupplied by the client institution, in addition to contact informationfor the client institution (usually for the contract manager) and forthe primary scheduler. It may also capture the reasons for the referral,the types of services expected to be rendered (e.g., blood tests), orthe circumstances for the referral (e.g., the patient has a medicalcondition such as diabetes). This referral may be generated by a doctoror clinician or, in some circumstances, by the patient (e.g., preferredprovider organizations (PPOs)).

Each electronic referral is assigned a unique referral identificationcode and, in step 210, the referrals are queued in a centralizedscheduling queue of a scheduling module. In step 215, a schedulerselects a referral from the centralized scheduling queue and schedulesan appointment for the selected referral. In most instances, thescheduler is a person. Additionally, in most cases, the scheduler willschedule the appointment with a service provider(s) identified in aparticular network of service providers associated with the clientinstitution. Typically, the scheduler will schedule the appointment bytelephoning or otherwise communicating directly with the serviceprovider. In the event that there is no provider in the network for aparticular requested service, the scheduler can attempt to recruit aservice provider in the required specialty and negotiate asingle-patient agreement for the appointment. When scheduling anappointment, the scheduler may take into consideration any predefinedscheduling rules for the client institution and/or service provider(e.g., a scheduling rule for a correctional institution might specifythat only one maximum security inmate patient can be at an off-siteappointment at a time).

Next, in step 110, appointment information corresponding to each of thescheduled appointments is generated. FIG. 3 illustrates detailed stepsfor executing step 110. As will be described in more detail below withrespect to the detailed description of the exemplary implementation, instep 305, the scheduler (or other user) views an electronic referral andcan select corresponding appointment information from predefined menusof appointment information (e.g., service provider, appointment date,appointment time, etc.). In one embodiment, the scheduler/user selects aunique service identifier code for each requested service that can beused as a cross-check against Medicare-defined service codes to validatereceived claims in subsequent steps. Some appointment information may bemanually keyed in by the scheduler/user, in which case a double-blindentry process can be implemented to detect and correct keying errors.The double-blind entry process entails two data entry people enteringthe same information, but “blind” to each other. Discrepancies are thenidentified and resolved, usually by a third person, particularly whenthe discrepancy is not automatically resolvable through spell-checker orgrammar-checker software components. Additionally, the scheduler/usercan use the scheduling module to attach associated information files(e.g., x-ray films) as appointment information.

In step 310, a unique appointment identifier code can be assigned toeach of the scheduled appointments that can be used to link appointmentswith received claims in subsequent steps. Advantageously, in step 315,an audit history can be maintained for each of the scheduledappointments to track when each appointment was created, modified,canceled, etc. In step 320, each scheduled appointment can be displayedusing a calendar interface such that a user (e.g., the clientinstitution, the scheduler, the service provider, etc.) can select adisplayed scheduled appointment to access corresponding appointmentinformation, perhaps each user potentially having different accessrights to different types of appointment information.

In step 115, service information is captured that corresponds to claimsreceived from the service providers for payment of charges associatedwith services rendered by the service providers to the patients. FIG. 4illustrates detailed steps for executing step 115. In step 405, aservice information database may be automatically populated with serviceinformation corresponding to claims received in an electronic formatfrom the service providers. In step 410, the database may be manuallypopulated with service information corresponding to claims received in anon-electronic format from the service providers. In this latter case,the service information can be keyed into the database in accordancewith the double-blind entry process described above to detect andcorrect keying errors. In step 415, images of the claims can be storedin the database. Claims received in non-electronic format can be scannedto generate the claim images.

Optionally, in step 420, one or more reports can be generated based onindividual or aggregated service and/or appointment information, such aspredefined institution-specific reports, financial reports, contractreports, and utilization reports. In an embodiment, step 420 includes adhoc report generation. In another embodiment, step 420 includesgenerating a pricing service sheet that identifies a pricing structurefor a particular network of service providers.

In step 120, the process 100 further includes automatically identifying,using logic, fuzzy logic and/or artificial intelligence (AI), candidateappointments that correspond to a particular received claim based on adegree of similarity between the service information associated with theparticular received claim and the appointment information associatedwith the scheduled appointments. Any suitable logic, fuzzy logic, or AIsystem could be used and would likely be centrally optimized forcircumstances, particularly if the circumstances are dynamic. FIG. 5illustrates detailed steps for executing step 120. In step 505, theparticular received claim is intelligently routed from an adjudicationqueue of received claims to an adjudicator. In an embodiment, theparticular received claim is routed to an initial adjudicator that isdetermined to be available, and if the initial adjudicator does notrespond within a predetermined period of time, the particular receivedclaim is routed to another available adjudicator so that the receivedclaims do not lag in the adjudication queue.

Next, either steps 510-525 are performed or steps 530-545 are performed.In the first case, a duplicate check is performed in steps 510-520before an appointment match is performed in step 525. In particular, instep 510, already processed claims that correspond to a particularreceived claim are automatically identified using logic, fuzzy logicand/or AI based on a degree of similarity between the serviceinformation associated with the already processed claims and the serviceinformation associated with the particular received claim. In step 515,the identified already processed claims are analyzed to determine if theparticular received claim is a duplicate of any of the identifiedalready processed claims. In an embodiment, step 515 includes having theadjudicator analyze the identified already processed claims to determineif the service provider submitted a duplicate claim. In anotherembodiment, step 515 includes automatically determining if the serviceprovider submitted a duplicate claim. In step 520, duplicate claims areflagged for resolution.

Alternatively, in the latter case, after an appointment match isperformed in step 530, a duplicate match is performed in steps 535-545.In particular, in step 535, already processed claims that correspond toa particular received claim are automatically identified using logic,fuzzy logic and/or AI based on a degree of similarity between theservice information associated with the already processed claims and theservice information associated with the particular received claim. Instep 540, the identified already processed claims are analyzed todetermine if the particular received claim is a duplicate claim. In anembodiment, step 540 includes having the adjudicator analyze theidentified already processed claims to determine if the service providersubmitted a duplicate claim. In another embodiment, step 540 includesautomatically determining if the service provider submitted a duplicateclaim. In step 545, duplicate claims are flagged for resolution.

In an embodiment, steps 525 and 530 include displaying the candidateappointments for review by an adjudicator. The adjudicator can thendetermine whether to flag the particular received claim for resolutionor to present the particular received claim for payment. In anotherembodiment, steps 525 and 530 include only displaying for review by anadjudicator candidate appointments that do not directly correspond tothe particular received claim. In this case, candidate appointments thatdirectly correspond to the particular received claim may not bedisplayed for review by the adjudicator to further expedite thevalidation process.

In step 125 of the process 100, the particular received claim is flaggedfor resolution when none of the candidate appointments corresponds tothe particular received claim. FIG. 6 illustrates detailed steps forexecuting step 125. In step 605, the flagged claim is routed to one ormore trouble shooters for resolution (e.g., to the contract manager forpricing problems, to the service provider for duplicate claims, etc.).This process of routing flagged claims among trouble shooters isdescribed in more detail below with respect to the detailed descriptionof the exemplary implementation. Essentially, instead of flagged claimslagging in the adjudication queue, the flagged claim is advantageouslyrouted among various trouble shooters to address the problem with theflagged claim, or at least to identify where resolution has beenstymied. In step 610, an audit history of the routing of the flaggedclaim among the trouble shooters is compiled. Compiling an audit historycan be advantageous for motivating faster resolution by the troubleshooters of the problem associated with the flagged claim. In step 615,resolved flagged claims are routed to an adjudicator for expeditedvalidation. In one embodiment, the resolved claims can be routed to thetop of the adjudication queue so that they are adjudicated as quickly aspossible following resolution.

In step 130, the particular received claim is presented for payment whenat least one of the candidate appointments corresponds to the particularreceived claim. FIG. 7 illustrates detailed steps for executing step130. In step 705, a unique claim identifier code of the particularreceived claim can be associated with a unique appointment identifiercode of the candidate appointment that corresponds to the particularreceived claim. In this way, the candidate appointment and itsassociated appointment information can be electronically linked to theparticular received claim and its corresponding service information. Instep 710, a pricing signature for a service provider corresponding tothe particular received claim can be reviewed to verify a payment amountfor services rendered by the service provider. The “pricing signature”refers to unique information associated with the service provider thatassists in verifying the correct pricing. In step 715, a submissionreport can be generated that includes information about the routing ofthe particular received claim from the time the service informationcorresponding to particular received claim was captured to the time theparticular received claim was presented for payment. The submissionreport can then be forwarded to the client institution. In anembodiment, the submission report is electronically forwarded to theclient institution and includes selectable links to related appointmentand/or service information.

In an embodiment, steps 125 and 130 include automatically flagging theparticular received claim for resolution when none of the candidateappointments corresponds to the particular received claim, andautomatically presenting the particular received claim for payment whenat least one of the candidate appointments corresponds to the particularreceived claim, respectively, to expedite the validation process.

Optionally, the process 100 depicted in FIGS. 1-7 includes theadditional steps shown in FIG. 8. In step 805, scheduled appointmentsthat have not been identified as corresponding to any received claimswithin a predetermined period of time can be automatically detected. Instep 810, the scheduled appointments which have not been identified ascorresponding to any received claims within a predetermined period oftime can be queued for resolution by at least one trouble shooter. Thetrouble shooter can then contact the service provider(s) associated withthe scheduled appointment and request that a claim be submitted forpayment. In step 815, a scheduled appointment is removed from the queuewhen a received claim is identified that corresponds to the scheduledappointment and the identified received claim is presented for payment.In this way, the service providers are more likely to receive paymentfor all of the claims they are entitled to. Furthermore, if the serviceproviders are promptly paid, they are more likely to contract with theclient institutions to provide health care services.

In step 820, an anticipated number of received claims associated with aparticular scheduled appointment can be automatically determined, andthe particular scheduled appointment can be queued for resolution by thetrouble shooter when the particular scheduled appointment corresponds tofewer than the anticipated number of received claims within thepredetermined period of time. In this way, the particular scheduledappointment can be analyzed on a procedure or service basis to estimatehow many claims are anticipated to be received from the serviceproviders after the appointment occurs. When fewer than the anticipatednumber of claims is received within a predetermined period after theappointment occurs, the trouble shooter can contact the applicableservice provider(s) and request that the missing claims be submitted forpayment.

System Overview

FIG. 9 illustrates an exemplary high-level network 900 for implementinga system for determining the appropriateness of service provider claimsfor payment. As shown in FIG. 9, the system can be employed inconjunction with a computer-based system, where the elements can beimplemented in hardware, software, firmware, or combinations thereof.Network 900 includes client institution workstations 905, serviceprovider workstations 910, and scheduler and adjudicator workstations915. Each of the workstations is configured to communicate with anapplication server 930 via Secure Sockets Layer (SSL) internetconnections 935. As shown in FIG. 9, the schedulers and adjudicators 915can also access application server 930 via a secure closed networkconnection.

The server 930 includes processors and memory for hosting differentmodules, which are described in more detail below with respect to thedetailed description of the exemplary implementation. Briefly, thesystem for determining the appropriateness of service provider claimsfor payment includes a scheduling module configured to scheduleappointments for patients with the service providers 910 based onrequests for services from the client institution 905, and generateappointment information corresponding to each of the scheduledappointments. The appointment information can be stored in a database925.

The system further includes a claim intake module configured to receiveclaims from the service providers 910 for payment of charges associatedwith services rendered by the service providers 910 to the patients andcapture service information corresponding to each of the receivedclaims. The service information can also be stored in database 925.

The system also includes an adjudication module configured toautomatically identify candidate appointments that correspond to aparticular received claim based on a degree of similarity between theservice information associated with the particular received claim andthe appointment information associated with the scheduled appointments.The adjudication module is further configured to present the particularreceived claim for payment when at least one of the candidateappointments corresponds to the particular received claim and flag theparticular received claim for resolution when none of the candidateappointments corresponds to the particular received claim.

DETAILED DESCRIPTION OF EXEMPLARY IMPLEMENTATION

FIGS. 10A-10X illustrate an exemplary implementation of the systems andmethods described herein for determining the appropriateness of serviceprovider claims for payment in the context of providing health careservices to inmate patients in a correctional institution. Persons ofskill in the relevant art(s) will understand that the systems andmethods described herein need not be limited to the application ofproviding health care services to inmate patients in a correctionalinstitution, and can be applicable to providing health care services inother environments, in which control over patient access to the healthcare services can be exercised (e.g., school campuses, healthmaintenance originations (HMOs), military bases, psychiatricinstitutions, rehabilitation facilities, etc.). PPOs could also benefitby letting members log-on to a scheduling module for “self-referrals” atstep 105 of FIG. 1, for instance. Such institutions are referred toherein as “clients” and “client institutions.” Additionally, persons ofskill in the relevant art(s) will understand that the systems andmethods described herein need not be limited to health care services andproviders (e.g., hospitals, doctors, dentists, physicians assistants,therapists, nurse practitioners, etc.), but could possibly beimplemented in other service environments, as well.

Web-Based Scheduling Tool

FIGS. 10A-10R show images of an example web-based scheduling tool thatincludes a scheduling module, an appointments module, a claims module, areports module, and an administrator module. To ensure security, theweb-based scheduling tool can be implemented with Secure Sockets Layer(SSL) technology to encrypt information and provide authentication.Persons of skill in the relevant art(s) will understand that thescheduling tool need not be web-based and can be implemented in a secureclosed network.

Scheduling Module

When the client institution has a patient in need of medical services,the client can complete a referral request. Using the scheduling module,the client can enter patient information. FIG. 10A shows a PatientInformation dialog box 1001, which is a portion of the scheduling moduleaccessible at the client institution. In particular, the client canenter a code identifying the patient. In the example shown in FIG. 10A,the client enters a Register Number 1003, which is a unique numberassigned to an inmate that remains associated with the inmate wheneverincarcerated. If the patient's code has previously been entered into thescheduling module it can be stored indefinitely and the schedulingmodule can automatically complete the remaining fields of patientinformation. Conveniently, the scheduling module can be implemented topoll the client institution to check for information required tocomplete the fields to save the client time in completing the PatientInformation section 1001.

If the patient's code has not been previously entered into thescheduling module, the client can complete the remaining patientinformation fields shown in FIG. 10A, including name, gender,jurisdiction (i.e., the name of the organization responsible for thepatient, such as the Bureau of Prisons (BOP), the U.S. Marshall Service,etc.), calendar designator (i.e., on which calendar the appointmentshould be displayed, as will be described in more detail below), date ofbirth, and release date from the correctional institution (i.e., so thatthe institution does not pay for services rendered after the patient hadbeen released or leaves the institution). Persons of skill in therelevant art(s) will understand that the scheduling module can beimplemented with other patient information fields not shown in theexample of FIG. 10A. Additionally, as shown in FIG. 10A, patientinformation fields can be implemented as drop-down menus 1004 listingavailable options for completing a particular field, and links to aviewable calendar 1005 can be provided for convenient selection ofparticular dates. Furthermore, in addition to completing the patientinformation fields, the client can also attach pertinent patient files,such as x-ray films, etc.

Using the scheduling module, the client can then enter patientappointment information. FIG. 10B shows a Patent Appointment Informationdialog box 1007, which is another portion of the scheduling moduleaccessible at the client institution. In particular, the client canprovide an expenditure authorization code 1009. In the example of FIG.10B, the client provides a “YREG,” which is an authorization codespecific to the BOP. In this case, the client has the option ofselecting a checkbox 1011 to have the scheduling module automaticallyfill in the most recently used YREG. Other clients might provide apurchase order number, etc. instead of a YREG. The client also has theoption of entering a client-specific Suffix 1013 to help the clientfurther track the patient (e.g., the suffix might indicate a securitylevel associated with an inmate, a level of billing, or any otherclient-defined field). The client can also enter an Appointment TimeFrame 1014 to indicate a desired time frame for the appointment (e.g.,one week, next month, as soon as possible, patient taken to emergencyroom, etc.). As shown in FIG. 10B, the Appointment Time Frame field 1014can be implemented as a drop-down menu for faster completion. The clientalso has the option of entering in the Pertinent Information field 1015any pertinent information about the patient (e.g., to explain why thepatient was submitted to the emergency room or needs to see a particularspecialist, or to include other notes, such as the reminder shown inFIG. 10B).

Also shown as part of the Patient Appointment Information dialog box1007, is a Preliminary Estimate field 1017. Here the client can select aparticular Specialty from a drop-down menu 1019 and a correspondingProcedure from a nested drop-down menu of procedures 1021 available forthe selected specialty. Based on these selections, the scheduling modulecan automatically generate a preliminary estimate (e.g., $59.00 is thisexample) of the cost for the selected specialty/procedure combinationthat the client can use for planning and/or authorization purposes.

Having entered the pertinent patient and appointment information, theclient can forward the referral request to a Central Scheduler of thescheduling module. In the example of FIG. 10B, the client can select theCreate OSR link 1023 to forward the off-site referral (to request anappointment with a service provider to see the patient off-site) oron-site referral (to request an appointment with a service provider tosee the patient on-site), both referred to herein as OSRs, to theCentral Scheduler. The scheduling module can be configured toautomatically assign a unique referral identification code to each OSRand generate an electronic OSR that is forwarded to the CentralScheduler.

Using the scheduling module, a scheduler can create an appointment basedon the OSR. FIG. 10C shows a View OSR dialog box 1025, which is aportion of the scheduling Module accessible at the Central Schedulerthrough which a scheduler (or other user) can View, Edit, AttachConsult, Schedule Appointment, Create Queue, Print, and Cancelparticular OSRs. FIG. 10C shows an example electronic OSR 1027 thatincludes a contact information field 1029 for the client institutionContract Manager, a contact information field 1031 for the CentralScheduler Primary Contact, and a patient information field 1033 (i.e.,Inmate Information in this example) and a Pertinent Information field1035, which include information previously entered by the clientinstitution.

By selecting the Attach Consult button 1037, the scheduler/user canattach to an appointment a consultation sheet, such as a Standard Form(SF) 513, which is a form the client institution can complete tocommunicate the patient's condition directly to the service provider.The scheduling module can store images of attached consultation sheets.In this way, the scheduler/user can not re-write the verbiage of theform, potentially reducing possible liability for treatment error.Optionally, the client institution can use the scheduling module toaccess and complete an electronic Consultation Sheet 1039, as shown inFIG. 10D, which can then be printed and submitted to the contractmanager electronically, by facsimile, by paper mail, or by any othersuitable manner of submission.

The Central Scheduler can create a queue of OSRs that have beensubmitted by the client. A scheduler is then responsible for contactinga service provider in a network of service providers affiliated with theclient to schedule an appointment in accordance with each OSR. From theView OSR dialog box 1025 described above, the scheduler can select theSchedule Appointment button 1041 to enter appointment information for aparticular OSR. FIG. 10E shows a Scheduling Information dialog box 1043of the Central Scheduler, through which the scheduler completes variousappointment information fields. The client might have scheduling rulesthat the scheduler should consider when making the appointment with theservice provider, which are displayed in the Institution SchedulingRules field 1045. Any pertinent information that was entered by theclient is displayed in the Pertinent Information field 1047. FIG. 10Fshows a Contract Manger dialog box 1049 through which the contractmanger can communicate notes to the scheduler by completing the Note toScheduler field 1051. These notes appear in the Scheduler Notes field1053 of the Scheduling Information dialog box 1043, shown in FIG. 10E.Similarly, the scheduler can communicate any special instructions to thecontract manger and others by completing the Special Instructions field1055, also shown in FIG. 10E.

Among other information shown in FIG. 10E (i.e., Referred By, RequestedAppointment Date, and Specialty), the scheduler can complete theAppointment Information fields 1057, such as an Appointment Type 1059(e.g., Outpatient), Provider 1061, and Provider Location 1063. As shownin FIG. 10E, fields 1059-1063 can be implemented as drop-down menus forfaster completion. The scheduler can also indicate whether the providerwas contacted by selecting an appropriate Provider Contacted radiobutton 1065 (i.e., the scheduler might have left a message for theprovider). Next the scheduler can complete the applicable Jurisdiction1067 (e.g., Arkansas Dept. of Corrections (ADOC) in this example) andCalendar Designator 1068, which can be pre-selected based on the PatientInformation 1001 entered by the client in FIG. 10A. Like the preliminaryestimate calculated as shown in conjunction with the Patient AppointmentInformation dialog box 1007 in FIG. 10B, a Schedule Estimate 1069 can beautomatically calculated for the particular specialty/procedurecombination indicated (e.g., $59.00 for Radiology/X-Ray Leg in thisexample).

Additionally, the scheduler can select a unique Claim Type 1071, whichcan serve as an additional cross-check against corresponding Medicarecodes during claim adjudication. After scheduling the appointment, thescheduler can enter the Appointment Date 1073, Appointment Time 1075,and estimate the Appointment Length 1077 and Appointment End Time 1079,which may be useful information for the client if the patient needs tobe escorted to the appointment. Finally, the scheduling module typicallyis configured to automatically assign a unique Fund Control Number (FCN)1081 to each appointment, which can serve as an additional cross-checkagainst the corresponding fund authorization code (e.g., YREG code)during claim adjudication.

Advantageously, as shown in the Notes and Audit dialog box 1083 of FIG.10G, the scheduling module can be configured to maintain a completeaudit history of the scheduling process for each appointment. In theexample of FIG. 10G, the Notes/History field 1085 indicates when an OSRwas added to the Central Scheduler queue. Additionally, a user (i.e.,scheduler, contract manager, etc.) can add notes in the New Notes field1087 regarding a particular appointment that will subsequently appear inthe Notes/History field 1085.

Appointments Module

After an appointment is scheduled, the appointments module can beconfigured to display the scheduled appointment on a calendar, which canbe accessed by various users depending on established access rights. Inan embodiment, when the appointments module displays a scheduledappointment on the calendar, the scheduling module removes thecorresponding OSR from the Central Scheduler queue. FIG. 10H shows anexemplary view of a high-level calendar 1089, which displays numerousscheduled appointments. The appointments can be selectable so that auser can view and edit the corresponding appointment information.Calendar views can be customized according to the different types ofusers so that only information pertinent to a particular user isdisplayed for that user.

FIG. 101 shows an exemplary Appointment Add/Update Form 1091, throughwhich a user can modify and save, cancel or print the appointmentinformation for a selected appointment. Appointment information can bemodified by completing the various fields shown in the AppointmentInformation dialog box 1099, including patient information fields 1101,appointment information fields 1103, service provider information fields1105, Special Instructions field 1107 (to modify any specialinstructions entered via the Special Instructions field 1055 of theScheduling Information dialog box 1043 of FIG. 10E), Schedule Estimatefields 1109, and discharge information fields 1111 (because the clientinstitution should not pay for services rendered after the patient isdischarged from the institution). Additionally, the user can add patientstatus history information via the Patient Status History field 1113.For example, if the patient goes the hospital, it might be useful totrack when the patient's status changes from “emergency room” to“in-patient,” etc.

For some clients, such as the BOP, the patient might need to be escortedby a guard or other security personnel to the scheduled appointment. Inthis case, the client can access the appointments module to download andcomplete an escorted trip form. Typically, these forms are printed andcirculated for signatures at the client institution. As shown in FIG.10I, the client can select the Create Escorted Trip button 1093 todownload and complete an escorted trip form. An exemplary escorted tripform 1095 is shown in FIG. 10J. Also, for some requested procedures,such as dialysis, multiple appointments with the service providers mightbe required. Thus, as shown in FIG. 10I, a user can select the RecurringAppointment button 1097 to schedule all appointments associated with aparticular OSR. These appointments would optimally be displayed in thesame manner as other scheduled appointments as described below.

In addition to using the appointments module to view scheduledappointments on the calendar, a user can use the appointments module tofilter and sort the scheduled appointments. For example, as shown inFIG. 10K, a user can choose from an Appointments drop-down list 1115 toview the calendar, On-Site scheduled appointments, or Off-Site scheduledappointments. FIG. 10L shows an example listing 1117 of OffsiteAppointments. Using the drop-down menu 1119, a user can choose to viewopen appointments (shown in this example), active appointments,re-scheduled appointments, canceled appointments, etc. Additionally, theuser can enter a search term in the search field 1121 and select theSearch button 1123 to search all appointments for particular appointmentinformation, such as for a particular provider. A user can also sort allappointments by selecting a particular column of appointmentinformation. For example, the user may sort the appointments accordingto Appointment Date. FIG. 10M shows an example listing 1125 of OnsiteAppointments, which can be filtered, searched, and sorted in a mannersimilar to that described above for the Offsite Appointments listing1117 shown in FIG. 10L.

The appointments module can also be configured to enable thescheduler/user to attach a patient's medical record to an appointment.As shown in FIG. 10K, the scheduler can select the Medical Records tab1127 and browse a file repository 1128 for and attach a patient'smedical records. In addition to medical records, the scheduler/user canattach other files relating to a particular appointment (e.g., x-rayfilms). As shown in FIG. 10N, the scheduler/user can select the FileAttachments tab 1129 and browse the file repository 1130 for and attachother related files.

Like the scheduling module described above, the appointments module canadvantageously maintain a complete audit history of the appointmentcreation process for each appointment. As shown in the Notes/Historyfield 1133 of the Notes and Audit dialog box 1131 of FIG. 10O, the audithistory can reflect when a new appointment is created. The audit historycan also reflect when an appointment is modified, canceled, the patientis a no-show, etc. Additionally, a user (i.e., scheduler, contractmanager, etc.) can add notes in the New Notes field 1135 regarding aparticular appointment to subsequently be displayed in the Notes/Historyfield 1133.

Claim Intake Module

Claims from service providers relating to scheduled appointments arereceived and processed to capture claim information. As described abovewith respect FIGS. 1-8, service information from non-electronic claimscan be manually captured, while service information from electronicclaims can be automatically captured. In the case of manual entry, thedouble-blind entry process described above can be implemented to detectand correct keying errors. In both cases, an image of the received claimcan be generated and attached to each claim record. Discrepancies arethen identified and resolved, usually by a third person, particularlywhen the discrepancy is not automatically resolvable throughspell-checker or grammar-checker software components. Advantageously,when used in conjunction with the windows-based adjudication tool, whichis described in detail below, to link captured service information withcorresponding appointment information, the claims module can provide auser with significantly more information than conventional disparateappointment scheduling and claim processing applications.

Users, such as the client institution, service providers, andschedulers, can use the claims module to filter and sort processedclaims and select particular claims to view corresponding serviceinformation. For example, FIG. 10P illustrates a Claims dialog box 1137,in which processed claims are displayed. Using a drop-down menu 1142,processed claims from a particular year to present can be displayed.Corresponding service information, such as Claim Number, Provider andDate of Service, etc., can be organized in columns (note that some ofthe data has been redacted). The user can enter a search term in thesearch field 1139 and select the Search button 1141 to search all claimsfor particular service information, such as a particular serviceprovider. A user can also sort all claims by selecting a particularcolumn of service information. For example, the user may sort the claimsaccording to Date of Service.

A user can select a particular claim to view detailed serviceinformation for the selected claim. For example, FIG. 10Q shows a ClaimInformation dialog box 1143 that includes captured service information(note that some of the data has been redacted) for a selected claim. Theclaims module can be configured to selectively display claim amountinformation 1145 based on the user. For example, if the user is thescheduler, the scheduler should be able to view all of the claim amountinformation, including Claim Amount 1147 (i.e., the amount submitted bythe service provider), the Medicare Amount 1149 (i.e., the amountMedicare would cover for the claimed procedure), the Client Amount 1151(i.e., the amount the client institution pays), and the Provider amount1153 (i.e., the amount paid to the service provider). A service providershould be able use the claims module to view and sort claims that theservice provider has submitted but should not be able to view the ClientAmount 1151. Likewise, a client institution should be able to use theclaims module to view claims associated with its patients but should notbe able to view the Provider Amount 1153.

Reports Module

The reports module can be used to generate predefined proprietary or adhoc reports based on individual or aggregated service informationcaptured from processed claims. FIG. 10R shows a Reports dialog box 1155that identifies by Report Name 1157 and Description 1159 various reportsthat can be generated. For example, proprietary reports associated withparticular client institutions can be generated to provide suchinformation as the number of OSRs generated, the number of appointmentsscheduled, canceled, re-scheduled, etc., and aggregated financialinformation such as the total claim amount, the total savings, and thepercentage of savings. The Standard Utilization report 1163 is anexample report that allows a user to add filters and sort on any of theinformation captured by the web-based scheduling tool. For example, theclient institution might generate a report for all of the scheduledpathology appointments, showing aggregated financial information, suchas the total pathology claim amounts, the pathology claim histories,etc.

The reports module can also be used to access a Service Pricing Sheet1165 for a particular client institution. For example, by viewing theService Pricing Sheet 1 165, the client institution can quickly reviewthe pricing structures of their provider networks. The reports modulecan also be used to generate various Administrative reports 1167, asshown in FIG. 10R, which can be used to identify user roles andprivileges with respect to the web-base scheduling tool. The web-basedscheduling tool further includes an administrator module that anadministrator can use to define user roles and access privilegesassociated with the various modules, as well as to define and modify theprovider networks and corresponding service providers.

Windows-Based Adjudication Tool

As described above, the web-based scheduling tool can be configured totrack information throughout the entire appointment process, from thereferral request, to a scheduled appointment, to a processed claim. Thewindows-based adjudication tool, which is described in detail below, canadvantageously be configured to use the tracked information to determinethe appropriateness of claims received from service providers. FIGS.10S-10V show images of an example windows-based adjudication tool thatincludes an adjudication module and a claim tracker module.

Persons of skill in the relevant art(s) will understand that theadjudication tool need not be windows-based and can instead beimplemented as a secure web-based application.

Adjudication Module

Conventional claims processing systems typically provide littleprotection against fraudulent and erroneous claims. To reduce the numberof fraudulent and erroneous claims being paid, the adjudication modulecan advantageously determine the appropriateness of the received claimsby only submitting for payment received claims that can be matched toscheduled appointments. Unlike conventional disparate appointment andclaim processing systems and methods, the integrated scheduling andadjudication tools described herein can be configured to quickly andaccurately determine the appropriateness of the received claims.

The adjudication module can queue received claims in an adjudicationqueue and intelligently serve up unverified claims from the queue toavailable adjudicators for validation. An adjudicator can initiate asearch for candidate appointments that match a particular receivedclaim. The adjudication module can use logic, fuzzy logic and/or AI tocompare the service information associated with the particular receivedclaim to the appointment information associated with each of thescheduled appointments, and can weight each scheduled appointment basedon a degree of similarity to the particular received claim. Theadjudication module can also perform a duplicate check before or afterthe appointment match to determine whether the particular received claimis a duplicate of an already processed claim and to identify services ofthe particular received claim that are duplicate services (i.e.,multiple claims might be received for one appointment and the sameservice might be identified in more than one of the claims). Theadjudication process is described in more detail above in conjunctionwith FIGS. 1-8.

FIG. 10S shows an exemplary Claim & Appointment Match dialog box 1169 ofthe adjudication module in which a particular received claim can beidentified in the Working Claim field 1171 and several candidateappointments 1173 can be displayed according to degree of similaritynext to the working claim, with the best match occupying the firstposition adjacent to the working claim, and so forth. The accuracy ofthe adjudication module can be such that most of the time the correctappointment is placed in the first position adjacent to the workingclaim.

In the event that the adjudication module determines that an appointmentperfectly matches the working claim, the adjudication module can beconfigured to display the perfectly matching candidate appointmentdifferently, for instance by highlighting the perfectly matchingcandidate appointment in a particular color. The adjudicator canmanually validate the working claim by selecting a View Appointmentbutton 1177 to view the appointment information corresponding to thecandidate appointments and determine which one of the candidateappointments, if any, matches the working claim. The adjudication modulecan alternatively be configured to automatically validate claims forwhich a perfectly matching candidate appointment is identified so thatthe adjudicator need only manually validate those claims for which noperfectly matching appointments are identified.

As further shown in FIG. 10S, after the adjudicator identifies acandidate appointment that matches the working claim, the adjudicatorcan select the candidate appointment using the appropriate checkbox 1179and the Match On Selected Appointment button 1181. If the adjudicatordetermines that an appointment having a particular unique appointmentidentifier code matches the working claim, the adjudicator can selectthe Match To A Given Appointment ID button 1183 to digitally tie theunique claim identifier code of the working claim to the uniqueappointment identifier code of the matching appointment. If theadjudicator determines that none of the candidate appointments matchesthe working claim, the adjudicator can add a note defining the problemin the Notes field 1185 and select the No Appointment Match button 1187.In this case, the working claim can be “flagged” (i.e., identified insome fashion) as a problem claim and forwarded to the claim trackermodule for resolution as described below.

FIG. 10T shows an example Verifying Digital Claim dialog box 1189 (notethat some of the data has been redacted), which can be used to verifythe service information associated with a particular claim, such as theClaim Amount 1191. Note that this verification step can be bypassed oromitted. The adjudication process ends when the adjudicator verifies theworking claim and submits it for payment.

Claim Tracker Module

The windows-based adjudication tool can advantageously be configured toinclude a claim tracker module that intelligently routes a flagged claimto various trouble shooters in an attempt to resolve the problem in atimely manner (e.g., typically in as little as a few days for the claimtracker module, as opposed to a few months for conventional claimprocessing systems and methods). The trouble shooters can be groupedaccording to geographic regions and attempt to resolve the problemsassociated with the flagged claims in a queue of flagged claims fortheir particular region. For example, FIG. 10U shows an exemplary queueof open flagged claims 1193 for a particular region. A particular regioncan be selected using the drop-down menu 1195. In this case, the flaggedclaims for a Mid-Atlantic Regional Office (MARO) are displayed (notethat some of the service information has been redacted).

The claim tracker module can also be configured to generate customizedviews based on the user. For example, the claim tracker module can beconfigured to only display the flagged claims forwarded to a particularadjudicator or contract manager, and not display all of the flaggedclaims to each user. As shown in FIG. 10U, the user can executecustomized searches for flagged claims (e.g., flagged claims having aparticular problem) using the search field 1197, and reorder the displayof the flagged claims by sorting the flagged claims according to thevarious column categories (i.e., ID, Contract, Provider, EIN, Date ofService, Patient Number, Patient Last/First Name, Amount, etc.). Theuser can also select a particular View button 1199 to view a PDF file ofa claim image and a particular Select button 1201 to select a particularflagged claim and take steps to resolve the identified problem.

FIG. 10V shows a Claim History dialog box 1203 of the claim trackermodule for an exemplary flagged claim (note that some data has beenredacted). The Claim History dialog box 1203 can display relevantappointment and service information associated with the flagged claim,including an indication of the particular problem 1205 (e.g., Pricing inthis example). Each user can view an Activity History field 1212, whichcan indicate to whom the flagged claim has been routed, when it wasrouted, and what each user has done to try to resolve the problem. Eachuser that works on resolving the flagged claim can enter a comment inthe New Comment field 1209 and assign the flagged claim to another userfor further resolution by selecting a user from the Assigned Todrop-down list 1211. In this way, the claim tracker module mightmotivate the users to work to resolve the flagged claims in a timelyfashion, or at least might be used to identify where particular flaggedclaims are stymied.

For example, if the problem is no appointment was scheduled for theflagged claim (e.g., the patient had to go to the emergency room and theclient institution did not have time to complete a referral request),then the trouble shooter might attempt to determine which clientinstitution is associated with the flagged claim, and forward theflagged claim to the contract manager requesting that the contractmanager complete a referral request so that an appointment can becreated. In another example, if the problem is a pricing error (e.g., anappointment corresponds to the claim but the adjudicator could not finda contract with the service provider, who submitted the claim), thetrouble shooter might forward the claim to the contract manager to workout the pricing problem. In other cases, the trouble shooter mightforward the claim to the service provider, for example, if there is aMedicare problem (e.g., an incorrect Medicare code for the claimedservice).

The claim tracker module can be configured with a reporting feature toperiodically produce reports that monitor the progress of the differentregions (e.g., the report can identify flagged claims for which noactivity has occurred for several days, what flagged claims are beingresolved by contract mangers, an average length of time the flaggedclaims have been in the claim tracker module, etc.). Such reports can bebeneficial for expediting the time it takes to resolve the flaggedclaims so that service providers can get paid in a more timely fashion.A trouble shooter can indicate when the problem associated with aparticular flagged claim is resolved by selecting the Change to Completebutton 1213. In one embodiment, the claim tracker module can beconfigured to route the resolved flagged claim to the top of theadjudication queue so that it is validated by an adjudicator in anexpedited fashion. Additionally, the claim tracker module can beconfigured to remove the claim from the flagged claim queue only afterthe adjudicator submits the resolved flagged claim for payment.

Claims Acquisition Tool

In addition to the scheduling and adjudication tools described above, aclaims acquisition tool can be configured to identify appointments thathave not been associated with particular received claims by theadjudication module. By identifying and resolving such appointments, theclaims acquisition tool can recover claims for the service providers,making it more advantageous for the service provider to contract withthe client institution.

Based on the appointment information, the claims acquisition tool can beconfigured to determine what type of claim is anticipated for aparticular appointment. In this way, if no claim is received within apredetermined time period after the appointment is to have occurred, atrouble shooter can contact the service provider with whom theappointment was scheduled and determine whether the service provider hasalready submitted or is going to submit a corresponding claim. Theclaims acquisition tool can also be configured to analyze theappointment information and determine how many claims are anticipated tobe received for a particular appointment (i.e., for some appointments,multiple claims from one or more service providers might be anticipateddue to various procedures being performed at the appointment). In thisway, if the anticipated number of claims is not received within apredetermined time period after the appointment is to have occurred, atrouble shooter can contact the service provider(s) with whom theappointment was scheduled and determine whether the service provider hasalready submitted or is going to submit an anticipated claim.

Like the claim tracker module described above, the claims acquisitiontool can be configured to maintain a working list of appointments forwhich claims are expected. After the adjudication module associates aparticular received claim with an appointment in the claims acquisitiontool list, the appointment can be removed from the list. FIGS. 10W and10X show images of an example windows-based claims acquisition tool.Persons of skill the relevant art(s) will understand that the claimsacquisition tool need not be limited to a windows-based implementation,and can also be implemented in a web-based environment. FIG. 10W showsan exemplary list of Appointments without claims 1215 for a particularContract/Institution that can be selected from a drop-down menu 1217(note that some of the data has been redacted). A trouble shooter canexecute customized searches for particular types of appointments usingthe search field 1219 and reorder the display of the appointments bysorting the appointments according to the various column categories(i.e., Appointment ID, Appointment Date, Age, Patient Name, ProviderName, Scheduled Estimate, YREG, Last Contact, Next Contact, etc.). Thetrouble shooter can also select a particular appointment and view theassociated appointment information.

FIG. 10X shows an Appointment Detail dialog box 1221 for an exemplaryappointment without a claim that includes the associated appointmentinformation. Via the Appointment Detail dialog box 1221, the troubleshooter can add notes (e.g., to request information) by completing aNotes field 1223, and save new points of contact by completing a Pointof Contact field 1225 (e.g., when the original point of contact for aprovider is no longer valid and the new point of contact needs to benotified that a claim should be submitted for the appointment). Thetrouble shooter can also indicate whether electronic claims are expectedto be submitted by selecting the Electronic Claims checkbox 1227(service providers are encouraged to submit claims in electronic formatbecause electronic claims are less likely to be lost than non-electronicclaims and are therefore more likely to be paid reliably). Byintegrating the claims acquisition tool with the scheduling andadjudication tools described above, problem claims are more likely to beidentified and resolved in a timely fashion.

Conclusion

The present invention has been described with reference to severalexemplary embodiments, however, it will be readily apparent to personsof skill in the relevant art(s) that it is possible to embody theinvention in specific forms other than those of the exemplaryembodiments described above. This may be done without departing from thespirit of the invention. These exemplary embodiments are merelyillustrative and should not be considered restrictive in any way. Thescope of the invention is given by the appended claims, rather than thepreceding description, and all variations and equivalents which fallwithin the range of the claims are intended to be embraced therein.

1. A method for processing service provider claims for payment,comprising: scheduling appointments with the service providers;receiving claims from the service providers; analyzing the scheduledappointments to identify at least one scheduled appointmentcorresponding to each of the received claims; automatically detectingscheduled appointments not identified as corresponding to any of thereceived claims within a predetermined period of time; and notifyingrespective service providers that no claims have been received for thedetected scheduled appointments.
 2. The method of claim 1, furthercomprising queuing the detected scheduled appointments for resolution byat least one trouble shooter.
 3. The method of claim 2, furthercomprising removing a detected scheduled appointment from the queue whenthe detected scheduled appointment is identified as corresponding to areceived claim.
 4. The method of claim 1, further comprising: analyzingappointment information associated with a scheduled appointment todetermine an anticipated number of received claims corresponding to thescheduled appointment; and automatically flagging the scheduledappointment for resolution when the scheduled appointment is identifiedas corresponding to fewer than the anticipated number of received claimswithin a predetermined period of time.
 5. A recording medium on whichthe method for processing service provider claims for payment as claimedin claim 1 is recorded as a program code that can be executed by acomputer.
 6. A system for processing service provider claims forpayment, comprising: a scheduling module configured to scheduleappointments with the service providers; a claim intake moduleconfigured to receive claims from the service providers; an adjudicationmodule configured to identify at least one scheduled appointmentcorresponding to each of the received claims; and a claims acquisitionmodule configured to automatically detect scheduled appointments notidentified by the adjudication module as corresponding to any of thereceived claims within a predetermined period of time and notifyrespective service providers that no claims have been received for thedetected scheduled appointments.
 7. The system of claim 6, wherein theclaims acquisition module is configured to queue the detected scheduledappointments for resolution by at least one trouble shooter.
 8. Thesystem of claim 7, wherein the claims acquisition module is configuredto remove a detected scheduled appointment from the queue when thedetected scheduled appointment is identified as corresponding to areceived claim.
 9. The system of claim 6, wherein the claims acquisitionmodule is further configured to analyze appointment informationassociated with a scheduled appointment to determine an anticipatednumber of received claims corresponding to the scheduled appointment,and automatically flag the scheduled appointment for resolution when theadjudication module identifies the scheduled appointment ascorresponding to fewer than the anticipated number of received claimswithin a predetermined period of time.
 10. A system for processingservice provider claims for payment, comprising: means for schedulingappointments with the service providers; means for receiving claims fromthe service providers; means for analyzing the scheduled appointments toidentify at least one scheduled appointment corresponding to each of thereceived claims; and means for automatically detecting scheduledappointments not identified by the analyzing means as corresponding toany of the received claims within a predetermined period of time andnotifying respective service providers that no claims have been receivedfor the detected scheduled appointments.